ultrasound clin 2 (2007) 737–757 ultrasound guided ... · -ultrasound-guided aspiration of joint,...

Ultrasound Guided MusculoskeletalProceduresDavid Fessell, MDa,*, Marnix van Holsbeeck, MDb

Specific ultrasound (US)-guided procedures to bereviewed in this article include aspiration of joint,bursal, and periarticular fluid collections; aspira-tion of calcific tendinitis; injection of joints andbursa, tenotomy (needling) of tendinosis; andbiopsy of soft tissue masses. These proceduresmay be performed with imaging guidance, or insome cases may be performed blindly, using onlyanatomic landmarks. Imaging guidance can includefluoroscopy, CT, or US, and has several advantagesover procedures done using only anatomic land-marks. When imaging guidance is used, the proce-dure can be done safely and successfully, avoidingnerves, vessels, tendons, and other structures.With US guidance, the radiologist can visualizethe needle tip continually and assure that the nee-dle is placed precisely in the desired location.US has several additional advantages over CT or

fluoroscopic-guided procedures. US is relativelyinexpensive and widely available. It is portableand can be done at the bedside, in the ICU,

emergency department, or an office setting. Thecontralateral joint or limb can be evaluated easilyfor comparison and detection of subtle abnormali-ties. Correlation can be made with the patient’s siteof pain, with direct visualization of the anatomyand pathology at the symptomatic site. Pressure withthe transducer can be used to elicit symptoms orassess for compressibility of a fluid collection versusa solid mass. Procedures can be performed rapidlyand efficiently with a seamless transition betweensonographic evaluation and aspiration or biopsy.

Ultrasound-guided aspiration of joint,bursal, and peri-articular fluid collections

General technique

The technique for US-guided joint aspiration hasbeen described previously [1,2]. Sonographic evalu-ation of the joint and surrounding soft tissues intwo planes is first performed to assess for joint fluid,

U L T R A S O U N DC L I N I C S

Ultrasound Clin 2 (2007) 737–757

a Department of Radiology, University of Michigan Hospitals and Health Centers, Taubman Center, Room2910Q, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5326, USAb Department of Radiology, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202,USA* Corresponding author.E-mail address: [email protected] (D. Fessell).

- Ultrasound-guided aspiration of joint,bursal, and peri-articular fluidcollections

General techniqueShoulderElbowWrist and handHipKnee

Ankle- Ultrasound-guided injections- Ultrasound-guided aspiration of calcific

tendonitis- Ultrasound-guided tenotomy- Ultrasound-guided biopsy of soft tissue

masses- Summary- References

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bursal fluid, or other soft tissue fluid collectionssuch as an abscess (Fig. 1). This allows detectionof bursal or soft tissue collections that would beundetected by fluoroscopic or blind aspiration,and prevents potential contamination of an asepticjoint during blind or fluoroscopic aspirationthrough overlying infected tissue such as septic te-nosynovitis, or soft tissue abscess (Figs. 2 and 3).In some cases, sonographic evaluation may renderaspiration unnecessary, if no joint or soft tissuefluid is detected. If clinical suspicion is high, andno joint or soft tissue fluid is identified, injectionof nonbacteriostatic, sterile saline followed by jointaspiration also can be performed.The approach for US-guided joint aspiration is in

most cases similar to that used for arthrography, butcan be optimized by tailoring aspiration to thespecific location where fluid is visualized by US.A 20-gauge spinal needle with stylet and commer-cial arthrogram tray typically is used. A 7.5 MHz(or higher frequency) transducer is recommendedfor most joints. Hip aspiration may require a curvi-linear 5 MHz or lower frequency transducer. A com-pact or hockey stick transducer is used commonly,especially for smaller joints, and often providessuperior visualization of the needle within thesoft tissues when compared with a transducerwith a larger footprint.With ultrasound, intra-articular joint pathology

may be anechoic, hypoechoic, mixed, or less com-monly hyperechoic. The sonographic appearanceof a joint effusion is not predictive of infection. Fluidaspiration usually is more successful from the moreanechoic regions,while synovial or soft tissuebiopsyis more successful from the hypoechoic or mixed

regions. Doppler evaluation is performed routinely,bothof the surrounding soft tissues to exclude vascu-lar structures along the aspiration approach, andalso to evaluate for blood flowwithin and surround-ing the intra-articular pathology. Some effusionscaused by an infectious or inflammatory etiologycan have increased surrounding flow on Dopplerimaging. The absence of such flow does not excludeinfection, however. Doppler flowwithin a suspectedjoint effusion is consistent with synovitis, or otherjoint pathology, rather than fluid (Fig. 4) [2]. Theuse of Doppler evaluation in muscoskeletal proce-dures can be summarized as follows:

! Evaluation of joint fluid (no internal Dopp-ler flow) versus synovitis (may have internalflow)—absence of internal flow does notexclude synovitis.

! Evaluation of cystic (no internal Dopplerflow) versus solid soft tissues masses (mayhave internal flow)—absence of internalflow does not exclude a solid mass.

! Evaluation of hyperemia surrounding a jointeffusion—hyperemia can be seen in thesetting of infection but the absence of hyper-emia does not exclude infection.

! Doppler evaluation can aid visualization ofthe needle within the soft tissues.

In the differentiation between complex jointfluid and synovitis, joint recess compressibility,movement of intra-articular contents with trans-ducer pressure, joint recess collapse with jointmovement, and lack of internal flow on color orpower Doppler imaging suggest complex jointfluid.

Fig. 1. (A) Coronal sonogram at the lateral aspect of a prosthetic hip demonstrates a 9 cm by 3.4 cm hypoechoicfluid collection (arrowheads). Fluoroscopic hip joint aspiration 4 days prior yielded no fluid and did not detectthis fluid collection. (B) Transverse sonogram at the lateral aspect of the hip demonstrates the fluid collection(arrow) measuring 3.6 cm (" to ") by 3.4 cm (1 to 1) lateral to the cortex of the proximal femur (arrowheads).The hypoechoic collection was an abscess and was treated with surgical incision and drainage.

Fessell & van Holsbeeck738

After a joint effusion is detected, an appropriatelysized needle is selected by measuring the depthfrom the skin entry point to the deepest portionof the fluid. The skin is marked and the skin entrysite checked for accuracy in both longitudinal andtransverse planes. The skin is cleaned with Betadine(Purdue Pharma, Stamford, Connecticut) or Chlor-aprep (Enturia, Incorporated, Leawood, Kansas),

sterile drapes applied, and the transducer coveredwith a sterile probe cover. A freehand aspirationtechnique commonly is used, with constant moni-toring of the needle position with US. If there is dif-ficulty in visualizing the needle tip, minutemovements of the transducer are recommendedrather than advancement of the needle. Dopplerevaluation also can be helpful to detect the needlewithin the soft tissues (Fig. 5). The more parallelthe needle is to the surface of the transducer, thebetter the needle will be visualized as a linear hyper-echoic structure with posterior reverberation arti-fact. US machine settings of a single focal zoneand low persistence have been reported to improveneedle visualization in the soft tissues [3].Complications secondary toUS-guided joint aspi-

ration are unusual and should be less frequent thanwith fluoroscopic or blind aspiration given the con-stant visualization of the needle tip during aspira-tion [4]. Potential complications include iatrogenicinfection, bleeding, damage to neurovascular struc-tures, vasovagal reaction, and failure to aspirate fluidor detect infection. Discussion of potential compli-cations should be included in the preprocedure in-formed consent process. Performing aspirationwith the patient in the supine position is optimaland helps decrease any complications secondary toa vasovagal reaction. Difficulty with aspiration usu-ally is secondary to poor visualization of the needleduring the procedure, improper skinmarking, or in-ability to distinguish synovitis from fluid on the pre-aspiration ultrasound examination [2]. The use ofsonography for evaluating and guiding joint aspira-tion helps assure a safe and successful aspiration.

Shoulder

Both anterior access and posterior access to theglenohumeral joint have been described [5,6]. Forjoint aspiration, the authors prefer the posterior

Fig. 2. Transverse sonogram at the anterior aspect ofthe midfoot demonstrates the extensor digitorumtendons (single arrowheads) and peroneus tertius ten-don (double arrowheads) with surrounding complextenosynovitis (curved arrows). Fluid was aspiratedunder ultrasound guidance and grew Nocardia aster-oides. Fluoroscopic or blind aspiration of the anklejoint could have infected an aseptic ankle joint if theneedle had extended through this septic tenosynovi-tis. (FromFessellDP, JacobsonJA,Craig J, et al.Using so-nography to reveal and aspirate joint effusions. AJRAm J Roentgenol 2000;174:1353–62; with permission.)

Fig. 3. Longitudinal ultrasound of the dorsal wristdemonstrates hypoechoic tenosynovitis (small whitearrows) surrounding the extensor tendons (black ar-rows). The radiocarpal joint is noted (large arrow).Blind or fluoroscopic aspiration of the radiocarpaljoint through septic extensor tenosynovitis could in-fect an aseptic radiocarpal joint.

Fig. 4. Longitudinal sonogramof thehipdemonstratesahypoechoic effusion (arrows) superficial to the cortexof the femoral neck (arrowheads). Increased surround-ing flow is noted with power Doppler.

Ultrasound Guided Musculoskeletal Procedures 739

approach, because fluid usually is visualized mostreadily in this location, even when small in amount(Fig. 6). Dynamic scanning from a posterior ap-proach during abduction and adduction of thearm can aid visualization of even minute amountsof joint fluid, surrounding the posterosuperiorlabrum and superior to the humeral head(Fig. 7). For posterior aspiration, the patient issitting upright or leaning forward and must bemonitored closely for any signs of a vasovagal reac-tion. The circumflex scapular vessels and suprascap-ular nerve course medial to the glenoid rim andmust be avoided. Puncturing the joint capsulealong the medial aspect of the humeral head, lateralto the joint space, provides safe and effective access.Using this approach, successful needle placementhas been reported in 24 patients for arthrography,without complication [5]. Because the presence ofjoint fluid distends the joint capsule and makesthe target even larger, sonographically guided jointaspiration is an even simpler procedure than usingsonographic guidance for arthrography.For aspiration of the shoulder from an anterior

approach, the patient usually is positioned supine.When scanning axially, the puncture site is the mid-point between the coracoid and anteromedialhumeral head, similar to standard arthrography.The cephalic vein, axillary artery, and brachialplexus course medial to the coracoid. The needletip therefore always must remain lateral to thecoracoid. Using an anterior approach, successfulneedle placement has been reported in 50 patientsfor arthrography, without complication [6]. At theauthors institution typically only aspirate the

glenohumeral joint from an anterior approach ina patient who has to remain supine, or in a patientwho has loculated fluid located only in the anteriorjoint space on the preaspiration sonogram.The subacromial–subdeltoid bursa also can be

aspirated with sonographic guidance (Fig. 8). Theentire shoulder always should be scanned withultrasound to reveal such collections before any

Fig. 5. (A) Transverse sonogram during ultrasound-guided hip joint aspiration. The needle is difficult to detect.Arrow denotes the hip joint fluid, and arrowheads outline the cortex of the femoral neck. (B) Same image as(A), with power Doppler showing the aspiration needle (arrow). The use of Doppler can aide visualization ofthe needle during aspiration.

Fig. 6. Diagram illustrating the approach for posterioraspiration of the shoulder. The transducer is placedtransversely at the joint space and, the needle entersfrom a slight lateral to medial approach.


aspiration of the glenohumeral joint. Such bursalfluid collections would not be detected with fluoro-scopic joint aspiration or joint aspiration based onanatomic landmarks. Using sonography, septicbursitis thus can be aspirated without the dangerof the needle going too deep and into the gleno-humeral joint as potentially could happen withan aspiration based on anatomic landmarks or anaspiration using fluoroscopy.

Although seen infrequently, acromioclavicular(AC) joint sepsis is seen more commonly inimmune-compromised patients and intravenousdrug abusers [7]. Clinically, the presentation maymimic glenohumeral joint infection. Sonographycan exclude a septic glenohumeral joint and diag-nose an AC joint effusion, preventing a potentiallymissed diagnosis. Sonography of the acromioclavic-ular joint is performed in both the sagittal andcoronal planes to evaluate for distention of thejoint. Comparison with the contralateral side isuseful, as well as noting pain with transducer pres-sure on the acromioclavicular joint. The glenohum-eral joint and subacromial–subdeltoid bursa alsomust be evaluated with ultrasound to exclude fluidat these sites. The normal AC joint has been re-ported to have less than 3 mm of fluid, measuredfrom the joint capsule to the cortex [7]. Fluid collec-tions communicating with the acromioclavicularjoint most commonly are caused by an infectedjoint or secondary to a ganglion cyst (Fig. 9) [8].Paralabral cysts of the spinoglenoid and supra-

scapular notches commonly are associated withtears of the glenoid labrum (Fig. 10) [9]. Spinogle-noid notch cysts usually are aspirated from a poste-rior approach, similar to posterior shoulder jointaspiration (see Fig. 6). The larger the needle, theeasier the aspiration of the thick, gelatinous gan-glion fluid. If possible, the use of a 15 gauge, orlarger needle, is helpful. Paralabral cyst aspirationtypically is considered when there is suprascapularnerve compression as a temporizing measure beforesurgery. Ganglion cysts have been reported in theanterior shoulder, including the followinglocations: between the deltoid and subscapularistendon, between deltoid and biceps, and inferior

Fig. 7. Transverse ultrasound of the posterior gleno-humeral joint demonstrates a moderate amount offluid (large arrows) surrounding the triangular andechogenic posterior labrum (small arrows). Arrow-heads denote the cortex of the humeral head.

Fig. 8. (A) Longitudinal sonogram of the distal supraspinatus tendon and subacromial–subdeltoid bursa demon-strates a small amount of fluid in the bursa (large arrows). Small arrows denote the bursal surface of the supra-spinatus tendon. (B) Longitudinal sonogram of the subacromial–subdeltoid bursa in a different patientdemonstrates a small amount of fluid within the bursa (small arrows). The aspiration needle (large arrow) isnoted within the bursa. Arrowhead denotes the cortex of the greater tuberosity. Two milliliters of thick, yellowfluid were aspirated under ultrasound guidance. Sonographic guidance can assure safe aspiration of an infectedbursa without danger of entering the glenohumeral joint space.


to the coracoacromial ligament [10]. Chiou andcolleagues [10] reported 15 patients who had gan-glion cysts of the anterior aspect of the shoulder, as-pirated with US guidance. Follow-up ranged from 2to 24 months (mean 6.4 months). Thirteen of the15 had marked or complete pain relief, without ev-idence of recurrence of the ganglion or recurrenceof symptoms. Symptom relief in this study wasnot related to the amount of fluid aspirated. Thetwo patients without symptomatic relief followingaspiration also had concomitant rotator cuffpathology. Therefore caution should be exercisedregarding expectations of pain relief in patientswho have concurrent rotator cuff or other shoulderpathology. The approach for aspiration depends onthe location of the cyst, and US guidance affordsa high degree of flexibility in the choice of the aspi-ration approach. Aspiration of shoulder ganglia canbe a painful procedure. Premedication and closemonitoring for a vasovagal reaction is needed. Aspi-ration should be performed with the patient supine,or lying on his or her side whenever possible.

Elbow

Anterolateral, posterolateral, and posterior ap-proaches have been described for aspiration of the el-bow [2,11,12]. Palpation and puncture of the softspot at the posterolateral elbow frequently are usedfor blind aspiration. The soft spot is the center ofthe triangle formed by the olecranon process, radialhead, and lateral epicondyle [11]. A lateral approach,with puncture of the radiocapitellar joint, frequentlyis usedwith fluoroscopy when performing arthrogra-phy. For the posterior approach, the elbow is flexedand the olecranon fossa evaluatedwithUS in longitu-dinal and transverse planes (Fig. 11). This positionoptimizes detection of the smallest joint effusion[13]. Sonography from a posterior approach

demonstrates fluid in the olecranon fossa (Fig. 12).No major neurovascular structures are encounteredwith a posterior approach. Radiologists at the authorsinstitution have used the posterior approach success-fully and without complication.

Wrist and hand

For the radiocarpal joint, a dorsal approach is used foraspiration, with sonographic guidance to avoid ten-dons,nerves, andvessels (Fig. 13). Flexionof the jointcanaidneedleplacement aswithpositioning forwrist

Fig. 9. (A) Longitudinal ultrasound demonstrates a 5.1 " 4.5 " 1.6 cm mixed anechoic and hypoechoic fluid col-lection (small arrows) extending from the acromioclavicular joint (large arrow). (B) Longitudinal sonogram(merged split-screen image) demonstrates the fluid collection (small arrows), ACJ (large arrow), and distal supra-spinatus tendon (black arrows). Fluid was aspirated under sonographic guidance and grew Staphylococcus.Abbreviations: ACJ, acromioclavicular joint; SST, supraspinatus tendon.

Fig. 10. Transverse ultrasound of the posterior aspectof the glenohumeral joint demonstrates a 1 cmhypoe-choic paralabral cyst (black arrow) in the spinoglenoidnotch with a hypoechoic neck extending laterally(small white arrows) through an irregular and tornposterior labrum. The paralabral cyst was aspiratedunder ultrasound guidance.


arthrography. Fig. 14 demonstrates the sonographicappearance of fluid in the radiocarpal joint. Flowwithin a hypoechoic region on Doppler evaluationcan help distinguish synovitis, which can demon-strate flow on Doppler imaging, from fluid whichdoes not demonstrate internal Doppler signal. Theabsence of flow on Doppler evaluation, however,does not exclude synovitis. Gentle flexion and exten-sion of the wrist during sonography can show fluidcommunicating with the joint and help distinguisha joint effusion froma ganglion cyst. Theflexibility af-forded by sonographically guided aspiration allowsplacement of the aspiration needle at the site of max-imal fluid. US evaluation and guidance of aspirationalso allow detection of extensor tenosynovitis, whichclinically could mimic a septic joint. Diagnosis ofsuch extra-articular fluid collections allows propertreatment and helps avoid potential complicationssuch as seeding of an aseptic joint from needle place-ment through an undiagnosed superficial abscess orseptic tenosynovitis (see Fig. 3).Wrist ganglia aremost commonly located dorsally,

adjacent to the scapholunate ligament, and at the vo-lar aspect of the wrist, adjacent to the radial artery. AtUS, they aremost commonly anechoic, possiblymul-tilocular and multilobular, and may be septated.Smaller ganglion cysts may be hypoechoic and maynot show increased through transmission [14]. UScan detect a ganglion cyst, and US guided aspirationand steroid injection can be used as treatment, withawareness that recurrencemayoccur (Fig. 15).Dopp-ler imaging can help exclude an aneurysm or othervascular process as the etiology for a wrist mass. Un-like a distended joint recess, wrist ganglion cysts are

typically not compressible, do not deform with jointmovement, and are more likely multilocular.For aspiration of the metacarpophalangeal joints,

proximal interphalangeal joints, and distal inter-phalangeal joints, a dorsomedial, or dorsolateralapproach can be used (Fig. 16). This approachavoids the medial and lateral neurovascular struc-tures and volar and dorsal tendons. The specific ap-proach used in a given case can be tailored to thesite of greatest fluid accumulation and site of easiestaspiration. When compared with attempted intra-articular needle placement based on anatomic land-marks, US-guided placement is more accurate bya wide margin, 56% to 96% [15]. US guidance

Fig. 11. (A) Diagram from a lateral view illustrating aspiration of the elbow from a posterior approach. The nee-dle tip is place in the olecranon fossa. Note that the transducer is oriented transversely, and the needle enterssuperior to the transducer. (B) Diagram from a posterior view illustrates the transverse orientation of the trans-ducer and needle entering superior to the transducer. If there is enough space, a longitudinal approach, withthe needle at the end of the transducer, can also be used.

Fig. 12. Transverse ultrasound of the posterior elbowdemonstrates a hypoechoic effusion (large arrows) inthe olecranon fossa. Small arrows denote the cortexof the olecranon fossa.


also is more successful for aspiration of joint fluid,versus aspiration using only anatomic landmarks,especially in the small joints. Balint and colleagues[16] showed aspiration based on landmarks wassuccessful in 32%, versus 97% with US guidance.

Hip

In the authors’ practice, the hip is the joint mostcommonly requested for aspiration. At the authors’

institution, they advocate the use of US for evalua-tion of hip joint fluid and soft tissue fluid collec-tions about the hip, especially in the patient whohas undergone a hip arthroplasty. In such patientsinfected soft tissue fluid collections are not unusual,and commonly would not be detected by a blind orfluoroscopic aspiration. Optimal patient position-ing for sonographic evaluation of the hip is withthe patient supine with the hip extended and theleg in slight abduction. This position tightens theposterior capsule and forces joint fluid into the an-terior portion of the hip capsule, aiding aspirationfrom an anterior approach [17].Given the depth of the hip joint, a 7.5 MHz or 5

MHz transducer most often is used. The transduceris oriented along the long axis of the femoral neck.This allows visualization of the femoral vessels,joint fluid, and needle as it enters the joint capsule.For safe aspiration, palpation and marking of thefemoral artery are performed. Joint aspiration isperformed lateral to the neurovascular bundle, usu-ally by several centimeters (Fig. 17).Displacement of the hip joint capsule away from

the femoral neck is noted with a hip effusion(Fig. 18). Contralateral comparison is performedeasily with US, and aids detection of subtle or smalleffusions. A 2 mm or greater difference in jointdistention between the symptomatic and asymp-tomatic hip has been reported as a helpful discrim-inator for the presence of abnormal fluid in the hipjoint [18]. Additional findings that may be seenwith a septic hip include thickening of the joint cap-sule and cortical irregularity of the proximal femurdeep to the effusion [18]. Preaspiration Dopplerevaluation to discriminate synovitis from fluid,and sonographic visualization of the needle tip inthe region of interest, can help assure a successfulaspiration. Although joint aspiration does nothave an accuracy of 100% compared with surgical

Fig. 13. Diagram illustrating aspiration of the radio-carpal joint from a dorsal approach. Transducer isplaced transversely at the level of the radiocarpaljoint. The tip of the needle is placed in the radiocar-pal space.

Fig. 14. (A) Longitudinal ultrasound of the wrist demonstrates a small amount of fluid dorsal to the scaphoid(large arrow). Distal radius (left gray arrow) and carpal bones (middle and right gray arrows) are noted. Super-ficial extensor tendon (small arrows) is intact. (B) Longitudinal ultrasound of a different wrist demonstratesa small amount of hypoechoic fluid (black arrows) in the radiocarpal and midcarpal joints, superficial to the car-pal bones (white arrows). Absence of flow within this hypoechoic region on Doppler imaging helps distinguishjoint fluid from synovitis. Arrowhead denotes the distal radius.


findings, it can be a helpful procedure, especiallycombined with US of the soft tissues to exclude bur-sal fluid or soft tissue abscess. Aspiration of thejoint is most helpful when fluid is obtained andconfirms a clinical suspicion of infection. Aspira-tion is less helpful when no fluid can be aspirated.In this situation, a negative aspiration can suggestthe absence of infection but does not exclude infec-tion definitively. This is especially true in the settingof a total hip arthroplasty [19].In cases with a hip prosthesis present, US findings

of capsular distention may have decreased accuracy[19,20]. This may be secondary to hypoechoic scartissue at the expected site of the joint capsule, whichcan mimic hypoechoic joint fluid (Fig. 19). Dopp-ler evaluation can be especially helpful in such casesand should be included in the US evaluation. Flowwithin the intra-articular, hypoechoic region is con-sistent with synovitis, scar, or fibrous tissue ratherthan hypoechoic joint fluid. In the setting of a hipprosthesis, it is also important to image the incisionsite and surrounding soft tissues for fluid collection.The presence of joint effusion and associated extra-articular fluid collection suggests infection [21].Complications from hip aspiration are very rare.

In a series of 800 aspirations performed by Bermanand colleagues [4], no iatrogenic hip infectionswere noted. Other complications such as hema-toma are also unusual. Inability to differentiate sy-novitis from joint fluid and thus inability toaspirate fluid may be the most commonly encoun-tered difficulty with hip aspiration. Again, Dopplerevaluation may be helpful; however, aspiration ulti-mately may be needed to assess for joint fluid.Numerous extra-articular fluid collections com-

monly are seen about the hip, including greatertrochanteric bursitis, iliopsoas bursitis, and less

Fig. 15. (A) Ultrasound of the volar wrist demonstrates a 2.4 " 2.2 cm (between the1 and " calipers respectively)anechoic, lobulated ganglion cyst at the level of the radiocarpal joint (joint space not shown). (B) Sonographicguided aspiration demonstrates the needle tip (large arrow) within the ganglion cyst (small arrows).

Fig. 16. Diagram illustrating sonographic guidance foraspiration of the metacarpal–phalangeal joint. Trans-ducer is oriented transversely at the level of the joint.


commonly obturator bursitis (Figs. 20 and 21). Un-like the bursae about the greater trochanter, theiliopsoas bursa may communicate to the hip joint;therefore, hip joint pathology and effusion may bethe cause of iliopsoas bursa distention. Soft tissueabscesses also can occur about the hip. These fluidcollections would be undetected by a fluoroscopicor blind aspiration of the hip. Given their depth,they may not be detected on physical examination.Sonography allows rapid and inexpensive detectionof these soft tissue fluid collections. For greater tro-chanteric bursitis, a lateral aspiration approach gen-erally is used. For iliopsoas bursitis, an anterior oranterolateral approach is often optimal. The flexi-bility of sonographic aspiration is one its strengthsand the precise location of the fluid collection andadjacent neurovascular structures determine the ex-act aspiration approach in each case. Fig. 22 illus-trates a posterior approach for aspirating loculatedfluid at the posterior aspect of the hip.

Knee

US has been shown to be more sensitive than clin-ical examination for detecting knee effusions andBaker’s cysts [22]. Blind knee aspiration often is per-formed easily using anatomic landmarks, especiallyif the effusion is moderate or large in size. Small orloculated effusions, however, can be aspirated usingsonographic guidance. The patient is supine withthe knee extended. Scanning of the suprapatellar re-cess and surrounding soft tissues is performed in

longitudinal (Fig. 23) and transverse orientations(Fig. 24) relative to the quadriceps tendon. The lat-eral aspect of the suprapatellar recess is the locationwhere small effusions are usually first detectable. Itis important not to apply too much pressure withthe transducer, as this may cause collapse the me-dial or lateral recesses. In partial knee flexion, jointfluid often predominately collects anteriorly, deepto the quadriceps tendon. A small amount of jointfluid is physiologic, and comparison to the contra-lateral knee aids determination of abnormal fluid.Aspiration can be performed from a medial or lat-eral approach and is usually done in a transverseorientation relative to the axis of the femur and pa-tella (Fig. 25). The precise location and entry pointcan be determined based on the site of greatest fluidaccumulation.Numerous bursa and cysts can exist about the

knee. These include the pes anserine bursa andsemimembranosus medial collateral ligamentbursa, Baker’s cysts, meniscal cysts, and ganglioncysts. All can be detected and aspirated with sono-graphic guidance. Aspiration of meniscal cysts usingUS guidance has been reported to provide symp-tomatic relief in two-thirds of cases, followed foran average of 10 months after aspiration [23]. Aspi-ration of posterior cruciate ganglion cysts also hasbeen reported [24]. US-guided aspiration of Baker’scysts can be performed for symptomatic relief andas a temporizing measure, because recurrence isnot uncommon following aspiration. Aspirationwith steroid injection may help prevent recurrencein some cases. When imaging a Baker’s cyst, visual-ization of fluid extending between the medial headof the gastrocnemius tendon and the semimembra-nosus tendon is essential to avoid confusion withother cystic masses about the knee (Fig. 26) [25].Abscesses and other cystic masses such as cystic lip-osarcoma, and myxoma, can occur in the poplitealfossa but do not have a neck extending between thesemimembranosus and medial head of the gastroc-nemius tendons (Fig. 27).

Ankle

For aspiration of the ankle joint, the patient is su-pine; the knee is flexed, and the plantar aspect ofthe foot is flush with the stretcher (Fig. 28) [2].Plantar flexion optimizes detection of an ankle effu-sion by distending the anterior joint recess. Normalankle joint fluid can measure up to 3 mm in thick-ness (anterior to posterior dimension) and can beasymmetric compared with the asymptomatic ankle[26]. Prior to aspiration, the dorsalis pedis artery islocalized with sonography and marked on the skin.The deep peroneal nerve courses immediately lat-eral to the artery. A skin entry site is chosen to avoid

Fig. 17. Diagram of hip joint aspiration. Note trans-ducer and aspiration needle are oriented along theaxis of the femoral neck (dotted line). Safe aspirationis performed lateral to the femoral vessels.


the neurovascular bundle and extensor tendons(Fig. 29). The needle can be visualized throughoutits course, ensuring a safe and successful aspiration.Septic tenosynovitis of the extensor tendons can

mimic a septic joint clinically. Sonography can de-tect such extra-articular fluid collections and guideaspiration. This avoids potentially infecting anaseptic joint by blind or fluoroscopic aspirationthrough overlying septic tenosynovitis or othersources of soft tissue infection (see Fig. 2) [2].Ganglion cysts about the ankle are relatively

common and frequently located at the lateral an-kle, related to the subtalar joint and sinus tarsi(Fig. 30). Surgical resection and obliteration ofthe neck of the ganglion is the mainstay of treat-ment. Aspiration does not obliterate the neck ofthe cyst; therefore cyst recurrence is not uncommonfollowing aspiration. In some cases, US-guidedaspiration may be requested and can be used asa temporizing measure or used as treatment innonsurgical candidates. Injection of corticosteroidsfollowing aspiration may help prevent recurrence[27].

Fig. 18. (A) Diagram showing the normal hip joint with superficial and deep layers of the capsule. The adjacentand opposed layers of the joint capsule should not be mistaken for hypoechoic fluid at sonography. (B) Diagramshowing a hip joint effusion distending the joint capsule. (C) Longitudinal ultrasound shows an anechoic hipjoint effusion (between the cursors) distending the capsule of the hip joint over the femoral neck. (Courtesyof J. Jacobson, MD, Ann Arbor, MI.)

Fig. 19. Longitudinal sonogram of a hypoechoic hip ef-fusion in a patient status after hip arthroplasty. Effusionis noted deep to the long arrowmarking the superficialportion of the joint capsule. The bone-to-capsule dis-tance is11mm,measuredbetweentheshortarrows.Re-verberation artifact is denoted by the curved arrowposterior to the metal flange of the hip prosthesis.(FromFessell DP, JacobsonJA, Craig J, etal.Using sonog-raphy to reveal and aspirate joint effusions. AJR Am JRoentgenol 2000;174:1353–62; with permission.)


Ultrasound-guided injections

US also can be used to guide injections of steroidor anesthetic into joints and bursae, and for treat-ment of ganglion cysts, Morton’s neuroma, andplantar fasciitis (see Box 1). The technique forplacing the needle in the joint or bursa is as de-scribed for aspiration. There are several advantagesof US guidance for musculoskeletal injections.The needle tip can be visualized constantly andmonitored for correct positioning. The steroid oranesthetic also can be injected precisely at the de-sired site. Injection within the substance of a ten-don, which has been associated with tendonrupture and degeneration, thus can be avoided[3]. Prior to injection, the joint, bursa or tendon

sheath should be aspirated, so that the injectedmedication is not diluted by fluid present in the in-jected space. The aspirated fluid can be sent foranalysis; however, septic joint fluid, septic bursalfluid, or septic tenosynovitis should be excludedclinically or by other means before the injectionof steroids.

Ultrasound-guided aspiration of calcifictendonitis

Calcific tendonitis can be treated by variousmethods, including anti-inflammatory drugs, phys-ical therapy and steroid injection. When conserva-tive therapy is unsuccessful, treatment can includeopen or arthroscopic surgery, US-guided aspiration,

Fig. 20. (A) Longitudinal sonogram at the posterolateral aspect of the hip demonstrating fluid distending thegreater trochanteric bursa (arrows). Arrowheads denote the cortex of the greater trochanter. (B) Transversesonogram at the posterolateral aspect of the hip demonstrating fluid distending the greater trochanteric bursa(arrows). Arrowhead denotes the cortex of the GT. (C) Axial T2 weighted magnetic resonance sequence with fatsaturation in the same patient demonstrates the fluid in the greater trochanteric bursa (arrows). Abbreviations:F/S, femoral shaft; GT, greater trochanter.


Fig. 21. (A) Transverse sonogram demonstrates a hypoechoic collection in the right iliopsoas bursa (arrow).Doppler shows the femoral vessels at the medial aspect of the bursa. Arrowheads denote the cortex of the fem-oral head. (B) Axial T2 weighted magnetic resonance sequence without fat saturation demonstrates a 2.8 cmfluid collection in the right iliopsoas bursa (white arrow) with a small posterior communication to the righthip joint. Note a tiny amount of fluid in the left iliopsoas bursa (black arrow).

Fig. 22. (A) Coronal short T1 inversion recovery magnetic resonance sequence demonstrates a lobulated fluidcollection (arrow) at the posterior aspect of the ilium, superior to the right hip joint. (B) Transverse sonogramat the posterior aspect of the hip, at the site of the fluid collection noted above demonstrates a lobulated, hy-poechoic collection (arrow) adjacent to the cortex of the ilium (arrowheads). (C) Transverse sonogram demon-strates the aspiration needle (large arrows) in the fluid collection (small arrow). Arrowhead denotes the cortexof the ilium.


and shock wave therapy. When first described, twolarge bore needles (18- to 19-gauge) were usedwith repeated punctures to fragment and aspiratethe calcification. One needle was used for injectionof saline and the second needle for aspiration.Water-soluble cortisone then was injected into thesubacromial–subdeltoid bursa to complete the pro-cedure. Clinical success rates were reported to beexcellent in 74%, moderate in 16%, and poor in10% of patients [32].In 2001, Aina and colleagues [33] described

a modified technique using a single, 22-gauge nee-dle. An anteroposterior axis of the needlewas recom-mended during aspiration, with the needle keptparallel to the horizontal axis (floor of the procedureroom). This orientation aided US localization of theneedle and helped prevent reinjection of aspiratedcalcium. If multiple calcifications were noted, thespecific one for aspiration was chosen based onthe largest size, the calcification associatedwith focaltendon swelling, or the most symptomatic with UStransducer pressure. Using US guidance, the needlewas placed in the center of the calcification andthe needle tip gently rotated followed by attempted

aspiration. If the consistency of the calcification waspaste-like; successive injection and aspiration of li-docaine was performed in an attempt to removethe calcification. Given the horizontal orientationof the syringe, the dense, white aspirate accumulatedin the dependent portion of the syringe (Fig. 31). Ifthe calcification was very hard and could be aspi-rated, grinding of the calcification was performedby means of gentle rotation of the needle tip in thehope of accelerating resumption. A mixture of ste-roid and anesthetic then was injected at the bursalsurface of the tendon and in the subacromial–subdeltoid bursa. In this study, the best clinicalresults were seen in those patients in whom calciumwas aspirated successfully [33].It may be most beneficial to first use a fine needle

(20- or 22-gauge) for aspiration, followed by a largerbore needle if no calcium can be aspirated; howeverdata using this technique have not been reported[33]. At the authors’ institution, the authors gener-ally use a 20-gauge needle and first attempt aspira-tion. If no calcium can be aspirated, they attempt tobreak up the calcification with the single needle. In-jection of approximately 1 cc of lidocaine within

Fig. 23. Sagittal sonogram of a suprapatellar effusion(medium-sized arrows), deep to the quadriceps ten-don (small arrows). The patella is noted by the largearrow.

Fig. 24. Transverse ultrasound of a small amount offluid in the lateral aspect of the suprapatellar recess(small arrows). The patella is denoted by the largearrow.

Fig. 25. Diagram illustrating aspiration of the kneefrom a lateral approach. The needle position is almosthorizontal, parallel to the floor.

Fig. 26. Transverse ultrasound of the popliteal fossademonstrating a Baker’s cyst, measuring 3.6 cm inmedial-to-lateral dimension, with internal debris.For confident diagnosis of a Baker’s cyst, an extensionof fluid (small white arrows) must be noted betweenthe semimembranosus tendon (white circle) and themedial head of gastrocnemius tendon (arrowhead).


the calcification is first performed before any at-tempted aspiration. This dilutes the calcificationand creates a pressure effect within the tissue andaids aspiration. Serial injection of lidocaine and as-piration of the calcification are usually successful. Amixture of corticosteroid and anesthetic is injectedinto the subacromial–subdeltoid bursa followingaspiration to help prevent postprocedure bursitis.Krasny and colleagues [34] compared US-guided

needling in conjunction with shock wave therapyversus shock wave therapy alone for treating calcifictendonitis of the shoulder. US-guided needlingcombined with shock wave therapy gave

significantly better outcome. To the authors’ knowl-edge, no study has compared US-guided needlingin conjunction with shock wave therapy with US-guided needling alone.

Ultrasound-guided tenotomy

Sonographically guided percutaneous needling ofa region of tendinosis also is known as tenotomy.This technique has been reported to be a safe andeffective treatment of tendinosis of the common ex-tensor tendon of the elbow, also known as tennis el-bow [35]. Compared with other treatment optionssuch as open or arthroscopic debridement, US-guided tenotomy is quick and easy and has lowmorbidity and a very low to nonexistent complica-tion rate [35]. The procedure is performed in thosepatients who have failed conservative managementsuch as blind corticosteroid injection, nonsteroidalanti-inflammatory medical treatment, bracing/splinting, and physical therapy. Sonography of theextensor tendon origin first is performed to confirmthe diagnosis. Typically, tendinosis of the commonextensor tendon is seen as tendon thickening withhypoechogenicity and heterogeneity of the tendon.Intrasubstance tendon tears and small regions ofcalcification and enthesophytes at the tendon at-tachment also may be seen.Following the diagnostic US to identify and local-

ize the region of tendinosis, the skin, subcutaneous

Fig. 27. Sonogram of the popliteal fossa demonstratesan 8.6 cm (1 to 1) " 3.0 cm (" to ") hypoechoic,poorly defined structure with internal septations.Incision and drainage revealed an abscess.

Fig. 28. (A) Diagram of the ankle joint from a lateral view illustrating transducer and needle placement for anklejoint aspiration. The tip of the needle is placed into the intra-articular space, along the anterior cortex of thetalus. (B) Diagram of the ankle joint from an anterior view demonstrating transducer and needle placementfor ankle joint aspiration.


tissue, common extensor tendon origin, and perios-teum of the lateral epicondyle are anesthetized withlidocaine or bupivacaine. McShane and colleagues[35] used an 18- or 20-gauge needle, with US guid-ance, to repeatedly fenestrate the area of tendinosis.An inferior-to-superior approach, parallel to thelongitudinal plane of the tendon, was used. Palpa-ble and audible crepitation can be noted on theinitial needle passes, and calcifications or entheso-phytes can be fragmented with the needle tip.McShane and colleagues [35] then inserted the nee-dle a superior to inferior approach, and used theneedle tip used to abrade the periosteum of the lat-eral epicondyle, smoothing any irregularities andfragmenting any enthesophytes. The tendon thenwas injected with a mixture of corticosteroid and

bupivacaine. In their hands, the procedure usuallytakes 15 to 20 minutes from start to finish. Postpro-cedure recommendations include a regimen of ice,passive stretching, restricted lifting/repetitive move-ments, and physical therapy.In 55 consecutive patients treated with US-guided

tenotomy, McShane and colleagues [35] had an av-erage follow-up time of 28 months, with 64% re-porting excellent results, 16% good, 7% fair, and13% poor. There were no adverse events. Eightyfive percent of their patients reported they would re-fer a friend or close relative for the procedure.US-guided tenotomy also has been reported for

treatment of chronic Achilles and patellar tendinop-athy. Color Doppler evaluation may demonstrateincreased flow in the region of tendinosis (Figs. 32and 33). As with chronic extensor tendinosis, a nee-dle canbe used to tenotomize the Achilles or patellartendon. Use of a scalpel, rather than a needle, alsohas been reported. In the studies by Testa and col-leagues [36,37], a #11 scalpel was used, under USguidance, to puncture and tenotomize the tendon.Flexion and extension of the knee or ankle, withthe scalpel in the tendon, was used to expand the re-gion of treatment. Results were similar for both theAchilles and patellar tendons, with approximately73% of patients reporting excellent or good resultson follow-up of at least 2 years. Nomajor complica-tions were reported. The tenotomy procedure didnot hinder surgical treatment in those patients

Fig. 29. Longitudinal sagittal power Doppler ultra-sound (US) at the anterior aspect of the ankle jointdemonstrates a hypoechoic joint effusion (small ar-rows) deep to the dorsalis pedis artery. Single largearrow denotes the cortex of the tibia, and doublelarge arrows denote the cortex of the talus. The effu-sion was aspirated under US guidance, avoiding thevessels and tendons.

Fig. 30. Lateral ankle ultrasound shows anechoicganglion cyst (arrows). Note needle (arrowheads)entering cyst for aspiration and steroid injection.(Courtesy of J. Jacobson, MD, Ann Arbor, MI.)

Box 1: Use of ultrasound for guidancefor musculoskeletal injections

Joint injection [3,5,6,28]Tendon sheath injection [3,28–30]

Biceps brachii tendon, long head (shoulder)Tibialis posterior tendonFlexor hallucis longus (ankle)Peroneal tendons (ankle)Extensor pollicis brevis and abductor pollicis

longus (wrist): for de Quervain’stenosynovitisIliopsoas tendon (hip): for snappingconditions

Bursal injection [3]

Retrocalcaneal (ankle)Subacromial–subdeltoid (shoulder)Greater trochanter (hip)Iliopsoas (hip)Pes anserine (knee)Olecranon bursa (elbow)Prepatellar bursa (knee)

Ganglion cyst injection, following aspiration[27]Morton’s neuroma injection [3,28]Plantar fascia injection [3,28,31]


who had unsatisfactory results from tenotomy. Lesssuccessful treatment with tenotomy was seen inAchilles tendons with marked paratenon involve-ment, multiple nodular regions, or tendinopathygreater than 3 cm in length. Insertional patellar ten-dinopathy also was treated less successfully with te-notomy comparedwith tendinopathy in the bodyofthe tendon. Corticosteroid injectionwas not used asa part of these procedures.

Ultrasound-guided biopsy of softtissue masses

Soft tissue masses frequently are biopsied percuta-neously, using a core biopsy system. Dependingon the specific size, location, and lesion characteris-tics, biopsy with CTor US guidance may be needed.Although sonography often cannot provide a spe-cific diagnosis of a given soft tissue tumor, its speed,efficiency, cost, portability, availability, and ease ofvisualizing vessels offer advantages over CT forguiding many biopsies. With US guidance, the nee-dle tip also can be visualized constantly, which in-creases the chance of a successful and safe biopsy(Fig. 34). In tumors that have regions of solid and

cystic or necrotic areas, the solid areas have thehighest yield, and the needle tip should be posi-tioned for biopsy of these regions (Fig. 35). Cer-tainly it is an advantage to the patient, clinician,and radiologist if US-guided biopsy can be offeredwhen it provides an advantage over blind or CT-guided biopsy.The biopsy approach must be chosen in conjunc-

tion with the orthopedic oncologist, because the bi-opsy tract may be seeded and may need to beresected if pathologic analysis reveals a malignantprimary tumor [38]. The most advantageous formof biopsy, whether imaging-guided or open surgicalbiopsy, can be determined bymeans of close collab-oration between the radiologist and orthopedic on-cologist. For US-guided biopsies, Torriani advocatesat least five core biopsies with a 14-gauge auto-mated biopsy gun. Lopez and colleagues [39] usean 18-gauge needle and an average of four biopsies,or a 14-gauge needle for suspected fatty masses. Theauthors routinely use a coaxial system with a 17-gauge introducer needle through which multiple18-gauge core biopsies are taken. Therefore, if fineneedle aspiration is performed, it is optimal to ob-tain these samples first, before obtaining any corebiopsy samples, because bleeding secondary to

Fig. 31. (A) Longitudinal sonogram of the distal supraspinatus tendon at its insertion on the greater tuberosity.Focus of linear, echogenic calcification is noted (large arrow) with needle (small arrows) extending through theregion of calcification during ultrasound (US)-guided aspiration. (B) Longitudinal sonogram of the distal supra-spinatus tendon in a different patient. Focus of globular, echogenic calcification is noted (large arrows) withneedle (small arrows) extending through the region of calcification during US-guided aspiration. (C) Photo-graph of the syringe following US-guided aspiration of calcific tendonitis. The white material in the dependentportion of the syringe is the aspirated calcium. (Fig 31C, Courtesy of J. Jacobson, MD, Ann Arbor, MI.)


the core biopsy sample can render a fine needle as-piration nondiagnostic. Core biopsy samples areusually more accurate and diagnostic comparedwith fine needle aspiration of soft tissue masses[38–40]. The introducer needle can be angled toobtain samples from different areas of the mass.

Following the biopsy, direct pressure should beheld for 15 minutes, and a compression bandageshould be used for 12 to 24 hours. At least 30 min-utes of observation in the department after biopsy isprudent to assess for bleeding or neurovascularcomplications [38].

Fig. 32. (A) Longitudinal sonogram of the proximal aspect of the patellar tendon demonstrates thickening andhypoechogenicity extending 1.3 cm (between the 1 cursors) from the proximal patellar attachment. Findingsare consistent with tendinosis. (B) Longitudinal ultrasound (US) with power Doppler imaging demonstrates hy-peremia of the region of tendinosis. (C) Longitudinal US during tenotomy demonstrates the needle (arrows)within the region of tendinosis. Needle is well-visualized when parallel to the surface of the US transducer.

Fig. 33. (A) Longitudinal ultrasound (US) of the Achilles tendon insertion on the calcaneus demonstrates thick-ening and hypoechogenicity with increased flow on color Doppler imaging. Arrows denote the Achilles tendon,and arrowhead denotes cortical irregularity at the calcaneal insertion. (B) Longitudinal US during tenotomydemonstrates the needle (arrow) within the region of tendonosis. Arrows denote the Achilles tendon. Needleis well-visualized when parallel to the surface of the US transducer.


Myxoid tumors or largely cystic tumors may notyield enough tissue for definitive diagnosis usinga core biopsy technique. Aspiration of fluid with cy-tologic analysis can be performed with US guid-ance. Ultimately, surgical resection may be neededfor definitive diagnosis in such cases. Althoughsoft tissue cartilaginous lesions are uncommon, itis often difficult to subtype and grade these lesions

based on needle biopsy. In such cases open biopsyor resection may be more efficacious.In a report of 188 US-guided musculoskeletal bi-

opsies performed by Lopez and colleagues [39], nomajor complications were noted. In most series,a complication rate of less than 1% is typical[38,40,41]. Pain, hematoma, and infection are themost common complications, with rare reports of

Fig. 34. (A) Sonogram demonstrates a hypoechoic mass in the thigh measuring 10 " 7 mm (large arrow) super-ficial to a subcutaneous vessel (small arrows). Clinically, there was concern for recurrent sarcoma at this site. (B)Ultrasound guided biopsy demonstrates needle (large arrow) within the mass (small arrows). Needle is well-visualized when parallel to the surface of the ultrasound transducer. Pathology revealed recurrent high-gradesarcoma.

Fig. 35. (A) Longitudinal sonogram of a mass at the medial aspect of the elbow. Proximal portion of the mass isshown with an echogenic component (arrow) and a linear hypoechoic peripheral nerve entering the mass(arrowheads). (B) Longitudinal sonogram of the distal and anechoic portion of the mass (arrow) is shownwith a linear hypoechoic peripheral nerve exiting the mass (arrowheads). (C) Longitudinal sonogram during bi-opsy demonstrates the needle (arrowheads) within the solid component of the mass seen in figure 35A. Pathol-ogy revealed a schwannoma.


more serious complications such as hemorrhage,severe neurologic damage, pneumothorax, or tuber-culous sinus tracts [38]. Accuracy of needle biopsy,compared with findings at surgical resection rangesfrom 60% to 97% [38,39,41–44]. For the patientwho has a soft tissuemass requiring biopsy, optimaloutcome is obtained at a treatment center whenthere is strong communication and cooperation be-tween experienced orthopedic oncologists, muscu-loskeletal radiologists, and musculoskeletalpathologists [39,42].

Summary

US guidance can be used for aspiration, injection,tenotomy, and soft tissue biopsy. The use of USguidance helps assure a safe and successful proce-dure. For each procedure, the precise approachcan be tailored to the specific site of fluid, tendonpathology, or mass. Nerves, vessels, and tendonscan be avoided, because the needle tip is monitoredconstantly with real-time sonographic visualiza-tion. US is widely available, portable, and allowsdynamic evaluation and rapid contralateral com-parison. Appropriate use of this powerful tool canbenefit patients and radiologists.

References

[1] Cardinal E, Chhem RK, Beauregard CG. Ultra-sound-guided interventional procedures in themusculoskeletal system. Radiol Clin North Am1998;36:597–604.

[2] Fessell DP, Jacobson JA, Craig J, et al. Using so-nography to reveal and aspirate joint effusions.AJR Am J Roentgenol 2000;174:1353–62.

[3] Sofka CM, Collins AJ, Adler RS. Use of ultraso-nographic guidance in interventional musculo-skeletal procedures: a review from a singleinstitution. J Ultrasound Med 2001;20:21–6.

[4] Berman L, Fink AM, Wilson D, et al. Technicalnote: identifying and aspirating hip effusions.Br J Radiol 1995;68:306–10.

[5] Cicak N, Matasovic T, Bajraktarevic T. Ultrasono-graphic guidance of needle placement for shoulderarthrography. J Ultrasound Med 1992;11:135–7.

[6] Valls R,Melloni P. Sonographic guidanceof needleposition for MR arthrography of the shoulder.AJR Am J Roentgenol 1997;169:845–7.

[7] Widman DS, Craig JG, van Holsbeeck MT. Sono-graphic detection, evaluation, and aspiration ofinfected acromioclavicular joints. Skeletal Radiol2001;30:388–92.

[8] Tshering Vogel DW, Steinbach LS, Hertel R, et al.Acromioclavicular joint cyst: nine cases of a pseu-dotumor of the shoulder. Skeletal Radiol 2005;34:260–5.

[9] Abboud JA, Silverberg D, Glaser DL, et al. Ar-throscopy effectively treats ganglion cysts of the

shoulder. Clin Orthop Relat Res 2006;444:129–33.

[10] Chiou HJ, Chou YH, Wu JJ, et al. Alternative andeffective treatment of shoulder ganglion cyst: ul-trasonographically guided aspiration. J Ultra-sound Med 1999;18:531–5.

[11] Cardone DA, Tallia AF. Diagnostic and therapeu-tic injection of the elbow region. Am Fam Physi-cian 2002;66:2097–100.

[12] Tang CW, Skaggs DL, Kay RM. Elbow aspirationand arthrogram: an alternative method. Am J Or-thop 2001;30:256.

[13] De Maeseneer M, Jacobson JA, Jaovisidha S, et al.Elbow effusions: distribution of joint fluid withflexion and extension and imaging implications.Invest Radiol 1998;33:117–25.

[14] Wang G, Jacobson JA, Feng FY, et al. Sonographyof wrist ganglion cysts: variable and noncysticappearances. J Ultrasound Med 2007;26:1323–8 [quiz: 1330–1].

[15] Raza K, Lee CY, Pilling D, et al. Ultrasound guid-ance allows accurate needle placement and aspi-ration from small joints in patients with earlyinflammatory arthritis. Rheumatology (Oxford)2003;42:976–9.

[16] Balint PV, Kane D, Hunter J, et al. Ultrasound-guided versus conventional joint and soft tissuefluid aspiration in rheumatology practice: a pilotstudy. J Rheumatol 2002;29:2209–13.

[17] Chan YL, Cheng JC, Metreweli C. Sonographicevaluation of hip effusion in children. Improvedvisualization with the hip in extension and ab-duction. Acta Radiol 1997;38:867–9.

[18] Shiv VK, Jain AK, Taneja K, et al. Sonography ofhip joint in infective arthritis. Can Assoc Radiol J1990;41:76–8.

[19] Eisler T, Svensson O, Engstrom CF, et al. Ultra-sound for diagnosis of infection in revision totalhip arthroplasty. J Arthroplasty 2001;16:1010–7.

[20] Weybright PN, Jacobson JA, Murry KH, et al.Limited effectiveness of sonography in revealinghip joint effusion: preliminary results in 21 adultpatients with native and postoperative hips. AJRAm J Roentgenol 2003;181:215–8.

[21] van Holsbeeck MT, Eyler WR, Sherman LS, et al.Detection of infection in loosened hip prosthe-ses: efficacy of sonography. AJR Am J Roentgenol1994;163:381–4.

[22] Kane D, Balint PV, Sturrock RD. Ultrasonogra-phy is superior to clinical examination in the de-tection and localization of knee joint effusion inrheumatoid arthritis. J Rheumatol 2003;30:966–71.

[23] Macmahon PJ, Brennan DD, Duke D, et al.Ultrasound-guided percutaneous drainage ofmeniscal cysts: preliminary clinical experience.Clin Radiol 2007;62:683–7.

[24] DeFriend DE, Schranz PJ, Silver DA. Ultrasound-guided aspiration of posterior cruciate ligamentganglion cysts. Skeletal Radiol 2001;30:411–4.

[25] Ward EE, Jacobson JA, Fessell DP, et al. Sono-graphic detection of Baker’s cysts: comparison


with MR imaging. AJR Am J Roentgenol 2001;176:373–80.

[26] Nazarian LN, Rawool NM, Martin CE, et al. Sy-novial fluid in the hindfoot and ankle: detectionof amount and distribution with US. Radiology1995;197:275–8.

[27] Breidahl WH, Adler RS. Ultrasound-guided injec-tion of ganglia with coricosteroids. SkeletalRadiol 1996;25:635–8.

[28] Sofka CM, Adler RS. Ultrasound-guided inter-ventions in the foot and ankle. Semin Musculos-kelet Radiol 2002;6:163–8.

[29] Femino JE, Jacobson JA, Craig CL, et al. Dynamicultrasound of the foot and ankle: adult and pedi-atric applications. Techniques in Foot and AnkleSurgery 2007;6:50–61.

[30] Flanum ME, Keene JS, Blankenbaker DG, et al.Arthroscopic treatment of the painful internalsnapping hip: results of a new endoscopic tech-nique and imaging protocol. Am J Sports Med2007;35:770–9.

[31] Tsai WC, Hsu CC, Chen CP, et al. Plantar fasciitistreated with local steroid injection: comparisonbetween sonographic and palpation guidance.J Clin Ultrasound 2006;34:12–6.

[32] Farin PU, Rasanen H, Jaroma H, et al. Rotatorcuff calcifications: treatment with ultrasound-guided percutaneous needle aspiration andlavage. Skeletal Radiol 1996;25:551–4.

[33] Aina R, Cardinal E, Bureau NJ, et al. Calcificshoulder tendinitis: treatment with modifiedUS-guided fine-needle technique. Radiology2001;221:455–61.

[34] Krasny C, Enenkel M, Aigner N, et al. Ultra-sound-guided needling combined with shockwave therapy for the treatment of calcifying ten-donitis of the shoulder. J Bone Joint Surg Br2005;87:501–7.

[35] McShane JM, Nazarian LN, Harwood MI. Sono-graphically guidedpercutaneousneedle tenotomyfor treatment of common extensor tendonosisin the elbow. J Ultrasound Med 2006;25:1281–9.

[36] Testa V, Capasso G, Benazzo F, et al. Manage-ment of Achilles tendinopathy by ultrasound-guided percutaneous tenotomy. Med Sci SportsExerc 2002;34:573–80.

[37] Testa V, Capasso G, Maffulli N, et al. Ultrasound-guided percutaneous longitudinal tenotomy forthe management of patellar tendinopathy. MedSci Sports Exerc 1999;31:1509–15.

[38] Torriani M, Etchebehere M, Amstalden E. Sono-graphically guided core needle biopsy of boneand soft tissue tumors. J Ultrasound Med 2002;21:275–81.

[39] Lopez JI, Del Cura JL, Zabala R, et al. Usefulnessand limitations of ultrasound-guided corebiopsy in the diagnosis of musculoskeletaltumours. APMIS 2005;113:353–60.

[40] Barth RJ Jr, Merino MJ, Solomon D, et al.A prospective study of the value of core needle bi-opsy and fine needle aspiration in the diagnosis ofsoft tissue masses. Surgery 1992;112:536–43.

[41] Ball AB, Fisher C, Pittam M, et al. Diagnosis ofsoft tissue tumours by Tru-Cut biopsy. Br J Surg1990;77:756–8.

[42] Mankin HJ, Mankin CJ, Simon MA. The hazardsof the biopsy, revisited. Members of the Muscu-loskeletal Tumor Society. J Bone Joint Surg Am1996;78:656–63.

[43] Welker JA, Henshaw RM, Jelinek J, et al. The per-cutaneous needle biopsy is safe and recommen-ded in the diagnosis of musculoskeletal masses.Cancer 2000;89:2677–86.

[44] Yao L, Nelson SD, Seeger LL, et al. Primarymusculoskeletal neoplasms: effectiveness ofcore needle biopsy. Radiology 1999;212:682–6.


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